INTRODUCTION Peripheral intravenous (iv) cannulation,most common invasive procedure , not easily obtained in all. Ÿ Multiple unsuccessful attempts associated with risks- nerve damage, paresthesia, hematoma, arterial puncture. Ÿ So necessary to have a predictive scale which identies high probability of a difcult iv access. Ÿ Adult-Difcult Intravenous Access (A-DIVA) score, proportionally weighted ve-variable. Ÿ 0-1 low risk , 2-3 medium risk & >4 high risk Ÿ Clinical rule, has been developed to predict failure of intravenous (IV) placement in adult. AIM OF THE STUDY Ÿ To externally validate A-DIVA scale Ÿ To rene the predictors of A-DIVA scale METHODOLOGY Prospective cross-sectional, clinical observational study. February 2019 to September 2019, MVJ Medical College Ethical committee approval and informed consent was taken. 500 subjects randomly selected Inclusion criteria: Aged >18 years irrespective of ASA grade undergoing peripheral IV placement before surgery Exclusion criteria : unresponsive patients and whose cannulation already gained in ward Socio- demographic prole sheet Clinical prole sheet A- DIVA scale The outcome of interest was dened as failure of cannulation on rst attempt. Scoring of the vein done according to A-DIVA scale Proposed renement predictor variables : age skin shade vein valves tortuous vein thrombosed vein operator experience site & side of cannulation. STATISTICAL ANALYSIS To compare patients regarding primary outcome, chi-square test and unpaired sample T-test were performed as appropriate Ÿ Potential risk factors identied in a univariate logistic regression analysis Ÿ Items with a P <0.001 were considered as statistically signicant with 95% condence interval(CI). RESULTS Ÿ Mean age of patients was 42.55 years (SD= ± 15.06 yrs) Ÿ 28%(140) subjects failed rst IV attempt. The original ve-variable model tested statistically signicant. Ÿ Hence additive 5-variable A-DIVA scale is a reliable predictive rule that implies the probability to identify patients with a difcult iv access prospectively. Ÿ The scoring system was applied in 3 risk groups as they failed rst attempt IV access- VALIDATION AND REFINEMENT OF THE ADULT DIFFICULT INTRAVENOUS ACCESS SCORE: A CLINICAL PREDICTION RULE FOR IDENTIFYING ADULTS WITH DIFFICULT INTRAVENOUS ACCESS Original Research Paper Dr Rahul Kishore X 55GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS Anaesthesiology KEYWORDS : VOLUME-9, ISSUE-1, JANUARY-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra A- DIVA score Risk grading (N) IV failure (%) 0 or 1 Low risk (424) 97 (22 %) 2 or 3 Medium risk (68) 36 (53 %) 4 plus High risk (8) 7 (87 %) 56 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS Addition variables predict failure of IV are:- DISCUSSION Ÿ Difcult intravenous access is a frequently encountered clinical challenge, which has been subject of research in various previous publications. Ÿ Reported success rates of rst attempt peripheral IV cannulation varies from 98% to as low as 51%, whereas our study shows an 72% success rate. Ÿ Failure to obtain a peripheral IV access can delay diagnosis and treatment, and may expose patients to risks associated with central venous cannulation. Ÿ No scoring system will precisely predict the outcome for a patient. Though, risk stratication helps eliminating bias against patients at high-risk for difcult intravenous access and may reduce complications related to the procedure. Ÿ Early recognition of patients at risk could help in applying alternative approaches, such as infrared(IR) assisted/ ultrasound guided IV catheter placement, to achieve a successful peripheral intravenous access. Ÿ In general, we believe it would not improve efcacy nor be cost-efcient to apply IR/ USG devices in all patients. Ÿ Furthermore, the proposed A-DIVA score may also be valuable in the evaluation of (cost-) efcacy and validation of the many venous access devices available in the market Ÿ As this study is a clinical observation study number of success and failure of IV access may alter depending on experience of operator. CONCLUSION This study validated the previously derived ve variable A- DIVA score. Ÿ Applying the A-DIVA scale to surgical patients may increase the success rate of inserting a peripheral intravenous catheter on the rst attempt. Otherwise, it creates a possibility to use other techniques, such as IR/USG, in an earlier time frame. Ÿ Certain newer renement variables are also found signicant may also be helpful. REFERENCES 1. Fredericus H. J. van Loon, Lisette A. P. M. Puijn, Saskia Houterman, et al. Development of the A-DIVA Scale: A Clinical Predictive Scale to Identify Difcult Intravenous Access in Adult Patients Based on Clinical Observations. Md-journal. Medicine _ Volume 95, Number 16, April 2016;1-8. 2. Yen K, Riegert A, Gorelick M. Derivation of the DIVA score: a clinical prediction rule for the identication of children with difcult intravenous access. Pediatr Emerg Care. 2008; 24:143–7. 3. Riker MW, Kennedy C, Winfrey BS, et al. Validation and renement of the difcult intravenous access score: a clinical prediction rule for identifying children with difcult intravenous access. Acad Emerg Med. 2011; 18: 1129– 1134. VOLUME-9, ISSUE-1, JANUARY-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Variables IV success IV failure t/ Chi square value P- value Tortous vein Yes 70 49 13.449 0.000* No 290 91 Phlebitis Yes 14 13 5.747 0.017* No 346 127 Valves + 68 86 85.584 0.000* - 292 54